OB

ASSESSMENT
 Definition of
Terms
OBSTETRICS
 medical specialty dealing with the
care of all women's reproductive
tracts and their children during
pregnancy, childbirth and the
postnatal period
Definition of
Terms
PREGNANCY
 is the fertilization and development
of one or more offspring, known as
an embryo or fetus, in a woman's
uterus.
 It is considered as a normal

physiologic process
Definition of
Terms
 Embryo is used to describe the
developing offspring during
the first 8 weeks following
conception, and subsequently
the term fetus is used
henceforth until birth.
Definition of
Terms
MENARCHE

is the first menstrual cycle, or first
menstrual bleeding, in female
human beings.

QUICKENING

– first fetal movement felt
Definition of Terms

POSTNATAL PERIOD

 begins immediately after the

birth of a child and then extends
for about six weeks.
Definition of
Terms
GESTATIONAL AGE

 refers to the number of

completed weeks based on the
LMP (Last Menstrual Period).
Definition of
terms
 GRAVIDITY - term for the state of pregnancy

 GRAVIDA – term for pregnant female

 PARITY/ PARA - is used for the number of previous

successful
live births.

 NULLIGRAVIDA - woman who has never been pregnant

 PRIMIGRAVIDA - a woman who is (or has been

only) pregnant for the first time

 MULTIGRAVIDA/ MULTIPAROUS - a woman in

PREGNANC
Y
 Divided into trimesters

 1st – missed period to 12 weeks

 2nd – 13th to 24 weeks
 3rd – 25 weeks onwards
PREGNANC
Y
 Length of pregnancy

 266 days to 294 days

 38 weeks – 42 weeks (40 weeks
average)
 9 calendar months and 10 lunar months
 Start period of viability – 24 weeks
PREGNANC
Y
 Diagnosis of pregnancy

- it is based on physical and related
hormonal changes and are classified as:

 1. Presumptive – subjective; not conclusive

 2. Probable – objective; not conclusive
 3. Positive – these are signs emanate from
fetus; conclusive
PRESUMPTIVE
SIGNS:
 FIRST TRIMESTER
 Amenorrhea

 Nausea and Vomiting

 Frequent urination

 Fatigue

 Uterine enlargement

 Quickening (second
trimester)
PRESUMPTIVE SIGNS:( 2nd Trimester)

LINEA NIGRA

 black line in the

midline of the
abdomen that may run
from the sternum or
umbilicus to the
symphysis pubis.
 PRESUMPTIVE SIGNS:(2nd trimester)
STRIAE GRAVIDARUM (stretch
marks)

 marks noted on the

abdomen and/or buttocks.

 marks are caused by

increased production or
sensitivity to adrenocortical
hormones during pregnancy,
not just weight gain.
PRESUMPTIVE SIGNS:(2nd Trimester)

CHLOASMA OR MELASMA

 brownish pigmentation
on the face.

 Due to overproduction
of melanin by the
pigment cells,
melanocytes.
 PRESUMPTIVE SIGNS: (ist
trimester
BREAST CHANGES

 nipples become sore a few weeks after

conception.

 breasts also increase in size

 Montgomery gland surrounding the

areola (pigmented region surrounding the
nipple) becomes darker and more
prominent,

 Areola darkens.

 nipples also become larger and more

erect
as they prepare for milk production.
PROBABLE SIGNS (1st
Trimester)
 Pregnancy tests (+) HCG

 Chadwick’s sign - bluish

discoloration of vagina and cervix

 Goodell’s sign – softening of the

cervix
PROBABLE SIGNS (1st trimester)

Hegars’s Sign
 – softening of

the lower
uterine
segment
PROBABLE SIGNS – (2nd trimester)

 Uterus and abdomen size

(becomes bigger)

 Braxton- Hick’s sign – irregular

painless contractions of the uterus

 Ballotement – fetus noted to

bounce or rise against the
examining hand
POSITIVE SIGNS (1st
trimester)
 Visualization of
embryo or
gestational sac
through ultrasound
(1 month – 1 ½
month)
POSITIVE SIGNS (2nd
trimester)
 Fetal heartbeat
When: 9th - 12th week using a Doppler
16th - 20th week using a fetoscope

 Fetal Movement (quickening) –(second trimester)

When: 20th week of pregnancy felt by a third party
(doctor)

 Fetal outline on X-ray

THE PRENATAL-
VISIT
Components
: 1. History taking


A. Personal Data

B. Obstetric Data
PRE NATAL VISIT -Obstetrical
Data
 T – number of term infant born
 P – number of preterm infant born

 A - number of pregnancy ending in spontaneous

or elective abortion
 L– number of living children

 M – number of multiple pregnancy (does

not change gravida or para)

 Nulli – (Gravida; Para) never

 Multi – (Gravida; Para) more than 1

THE PRENATAL-
VISIT
2. Assessment
A. Physical Assessment
B. Pelvic Examination – IE, PAP smear, pelvic
measurement/xray pelvimetry, Leopold’s
Maneuver
C. Vital Signs
D. Blood studies
E. Urine Examinations (Heat and Acetic
(Protein)/ Benedict’s Test (Glucose)
THE PRENATAL-
VISIT
 3. Important Estimates

 A. Age of Gestation (AOG)

 B. Expected Date of

Delivery/Confinement (EDD-
EDC)
 C. Length of fetus

 D. Weight of the fetus

Age of
Gestation McDonald’s Rule – to determine AOG in
weeks or lunar month

 FUNDIC HEIGHT

measurements from symphysis
pubis to up and over the fundus

fh in cm X 8/7=AOG in weeks
Example: 17cm x 8/7= 19.42 weeks

fh in cm X 2/7=AOG in lunar
months
Example: 17cm x2/7 = 4.8 months
Age of
Gestation Bartholomew’s Rule –
to estimate age of
gestation the location of
fundus at abdominal
cavity.

-3 months – above
symphysis pubis
-5 months – level of
umbilicus
-9 months – below
xyphoid
-10 months – level of 8
months due to
lightening
Estimates
:
 3 months – ½ from umbilicus to symphysis
pubis
 4 months – ¾
 5 months – level of umbilicus
 6 months – ¼ from umbilicus to xiphoid
 8 months- ¾
 9 months- just the xiphoid process
 10 months – level of 8 months due to
lightening
Expected Date of
Delivery
 Naegelle’s /Nagele’s Rule :

 Formula: + 7 days (-) 3 months from the

LMP

 Example:
◼ 12 LMP December
15 15, 2006
◼ -3 +7
◼
◼ 9 2007
22
NAEGELE’s
RULE
 Example:
 1. First day of last menstrual period = March
12.


2. Go back 3 months from March
12 = December 12.


3. Add 7 days to December 12 = December
19 is the due date

NAEGELE’s
RULE
 1. First day of last menstrual period = August 27


 2. Go back 3 months from August 27 = May

27


 3. Add 7 days to May 27 = June 3 (May had

31 days)
Length of
fetus
Haase’s rule – to estimate length of
the fetus in cm.

Formula:
- 1st ½ of pregnancy: square the number
of month
- 2nd ½ of pregnancy: number of month x 5
Haase’s Rule
Example:
1st half of pregnancy – 4 months
4x4 = 16 cm

2nd half of pregnancy – 7

months
7x 5 = 35 cm
 Weight of the
Fetus
JOHNSON’s RULE
– estimation of weight
of fetus in grams.

Formula:
fh –(n) x 155
n = 11 not engaged
n = + 1 (12) for
engaged
Johnson’s Rule Example

 17cm – 11 x 155 = 930

grams

 35 – 12 x 155 = 3565 grams

There are three types of breech presentation:
complete, incomplete, and frank.

Complete breech is when both of the baby's

knees are bent and his feet and bottom are
closest to the birth canal.

Incomplete breech is when one of the baby's

knees is bent and his foot and bottom are
closest to the birth canal.

Frank breech is when the baby's legs are

folded flat up against his head and his bottom
is closest to the birth canal.

There is also footling breech where one or

both feet are presenting.
 D r
s s or
r o fe h a n
e P h K
i a t l l a
s o c i f u
s n
A Ha

GESTA
TIONAL
AGE
ESTIM
ATION &
OF D U E
DATES

46
 OBJECTIVES

• Importance of determination
of gestational age
• Definitions of important
terminology
• Methods of determination
of gestational age
• Proper estimation of GA &
EDD
47
IMPORTANCE OF
DETERMINATION
OF
GESTATIONAL
AccurateAGE
•assessment determination of the
D u e Date (EDD) - one of the
Expected
m ost im portant factors
• Healthcare in early
preg nancy professionals
must take great pains to
determine accurate
gestation & EDD during
booking

48
 Accurate dating is vital for

• the timing of appropriate antenatal care

• scheduling & interpretation of tests
• determining appropriate fetal growth
• intervention purposes
prevention of preterm
birth prevent postdates
prevent comorbidities
• for research purposes
49
Gestational age can be
determi
ned by

Clinical History

Physical Examination

Ultrasound Scan

50
CLINICAL HISTORY

51
 Naegele’s Rule:
Determining the • ED D is 2 8 0 days from
the LNMP
gestational age • Must be regular cycles
for this to be accurate
using clinical history • Accuracy is up to 5 0%
within 7 days on either side

• Reliant on knowledge Inaccurate in patients in the

following circumstances:-
of accurate • Oligomenorrhoea or
polymenorrhagia (irregular
menstrual period cycles)
• Bleeding in the first trimester of
pregnancy (implantation
• 1st day of bleeding)
• Pregnancy following the use of
LMP oral contraceptives or
• calculation based intrauterine devices
• Pregnancy in the postpartum
on Naegele’s rule period (lactational amenorrhoea)

If the interval of cycles is longer than 28/7, the extra days are to be added
and if the interval is shorter, the days are to be subtracted to get the EDD
52
Confirm by time of
onset of pregnancy
symptoms

Using dates, early

• Typically, these begin pregnancy symptoms
around 5+ weeks of should occur about
gestation 5 - 6 weeks
from the 1st day of
• commonly include the LMP
nausea, headache,
loss of appetite etc..

53
 Add 22/52 in
primigravidae & 24/52
in multiparae to the date
of quickening = EDD

Time of Can be used as an

Quickening estimation in the
absence of other more
reliable methods

Inaccurate

54
 PHYSICAL
EXAMINATIO
N

55
 •P/E b itself is
P/E augments y
inaccurate
history • What it can do is
confirm to the
historical
findings
• P/E is more helpful
in later pregnancy

Height of the Uterus

Refers to the
Symphysio- Fundal-Height
(SFH) Corresponds with the
Period of Gestation (POG)
Is widely influenced by the state
of the pregnancy - may be
smaller or larger than dates
56
 If the cervix becomes
Very late shorter and dilated, labour
is not far off
pregnancy This suggests a term
pregnancy but cannot date
it conclusively
• If the gestation is uncertain
late on..
Cervical assessment
• cervical assessment may
indicate maturity • cervical length, position and
consistency are most useful
• as a component of the • a short, anterior and soft cervix
Bishop score, cervical is usually present after 3 8 weeks
assessment may help maturity
denote the likelihood of • although cervical shortening &
successful vaginal delivery position may not change,
changes in consistency almost
always do
57
Ultrasound scanning

58
 Not all scans during
Ultrasonography pregnancy serve the same
purpose

early pregnancy
scans are the
most accurate
for dating

midtrimester
scans are used
for anomaly
assessment
Crown-Rump Length (CRL)
3rd trimester
scans may assess
liquor volume &
fetal weight
accurately but
are useless for
dating
59
 It is crucial that the mother
Early Pregnancy is questioned if a scan was
done early in pregnancy
Scan If so, she should be asked if
the findings corresponded
to the LMP dates
• Termed as a scan done
b efore14weeks
gestation In clinical practice, if the
discrepancy between menstrual
• The CRL is the & u/s dates is < 7 days, the
desired measurement LMP dates should be employed
(as long as the periods are
• Accurate up to a day! regular)

• All mothers should have If the discrepancy is more then

this the EDD should be based on
ultrasonographic fetal biometry
60
The
EDD

61
 Estimation of the EDD

Amongst all the methods for EDD assessment,

a high quality ultrasound scan early in
pregnancy is the best estimate

EDD has traditionally been based on

LMP
but this has been found to be unreliable
as about half of women
cannot accurately recall the 1st day of their LMP,
have irregular menses
and the timing of ovulation varies
62
Summary

63
Estimation of GA & EDD is usually dependant on
history (LMP)

GA & EDD should be confirmed by

historical features, physical exam other and
ultrasound scan
early
A high quality ultrasound measurement of the
embryo or fetes within the 1st 14 weeks is the
most accurate method of confirming GA &
establishing EDD

The GA & EDD should be documented clearly in

the records as soon as confirmation is made via
an accurate calculation of the LMP, u/s or both
64
 REFERENCES
• Konar H, D.C. Dutta’s Textbook of Obstetrics, 7 t h
Edition, New Central Book Agency, 2 0 1 0

• Mongelli M and Gardosi J, Update 1 9 April 2010,

Evaluation of Gestation, Emedicine.medscape.com,
Extracted from:
http://emedicine.medscape.com/
article/259269-overview

• New guidelines standardize pregnancy due

date estimates. Medscape. Sep 2 5 2 0 1 4

65
 Accurate!

Thank You Very Much

66
 ERA’S COLLEGE OF
NURSING
PRESENTATION ON:
SIGN AND SYMPTOMS OF PREGNANCY

PRESENTED BY:
NIDHI MAURYA
Msc. Nursing
1st year
 OBJECTIVES OF
PRESENTATION
• At the end of presentation students will be:

•Able to define pregnancy.

•Able to explain signs and symptoms of first trimester.
•Able to explain signs and symptoms of second trimester.
•Able to explain signs and symptoms of third trimester
 INTRO
DUCTI
Signs and symptoms that are usually noted by the patient, which impel
ON
her to make an appointment with a physician for confirmation of
pregnancy .
 DEFINITION OF
PREGNANCY
It is the state of carrying a developing embryo or fetus
within the female body from conception to birth.
After the egg is fertilized by sperm and then implanted
in the lining of the uterus, it develops into placenta
and embryo or fetus.
 DURATION OF
PREGNANCY
1. Usually 40 weeks or
2. 280 days or 10 lunar months or
3. 9 months and 7 days, calculated from the first day of last menstrual
period.
Beginning from the first day of last menstrual period ,
It is divided into three
trimesters, each lasting three months.
First trimester ( First 12 weeks)
Second trimester ( 13-28 weeks)
Third trimester ( 29-40 weeks)
 FIRST TRIMESTER PRESUMPTIVE
SIGNS OR SUBJECTIVE
SYMPTOMS
AMENORRHOEA

MORNING SICKNESS

FREQUENCY OF MICTURITION

BREAST DISCOMFORT

FATIGU

E FAINTING
 AMENORRHOEA
• Absence of menstruation in woman of reproductive age.
• Since nine months during pregnancy periods are
not occurred .
• If any type of bleeding is occurred during 9 months
should not be confused with the commonly met
pathological bleeding .
E.g. – Threatened abortion.
 MORNING SICKNESS
• It is present in about 50% cases, mostly
during first pregnancy.
• Nausea and vomiting begins about 6
weeks after the last menstrual period and
usually disappears by about 14 weeks.
• It is due to the high level of
pregnancy hormones.
 FREQUENCY OF
MICTURITION
• Resting of bulky uterus on the fundus of the bladder because of anteverted position of
uterus.
• It is present during 8-12 week of pregnancy and subside after 12 weeks.
 BREAST
DISCOMFORT
• It is present during 6th week in the form of feeling of :
* Tenderness.
* Tingling.
* Fullness.
* Increase in size.
* Pigmentation of areola.
* Pricking sensation.
 FATIGU
E
• It is frequent in early pregnancy and subside around 12-14 weeks of pregnancy with
bringing renew energy
FIRST TRIMESTER PROBABLE SIGNS
OR OBJECTIVE SIGNS

• Breast changes
• Cardio-vascular changes
• Respiratory changes
• Integumentary changes
• Musculo-skeletal changes
• Abdomen and uterine changes
• Pelvic changes
 BREAST CHANGES

• These are valuable only in primiparae, compared to multiparae.

 Breast changes are evident between 6-8 weeks.

 There is enlargement with vascular engorgement with delicate veins visible under the skin due to
increased blood supply, making the veins more noticeable.

 Nipples and areola (primary) become more pigmented or darker.

 Montgomery’s tubercles are prominent.

 The thick yellowish secretion (colostrum) can be expressed as early as 12th week.
BREAST
CHANGES
 PELVIC
CHANGES
Jacquemier ’s or Chadwick’s sign:
It is dusky hue of vestibule and anterior vaginal wall visible at about 8th week of
pregnancy.
The discoloration is due to local vascular congestion.

Vaginal sign :
Apart from bluish discoloration of the anterior vaginal wall, walls become softened,
copious amount of non-irritating mucoid discharge appears at 6th week. There is
increased pulsation felt through the lateral fornices at 8th week called Osiander ’s Sign.

Cervical signs :
Cervix becomes soft as early as 6th week ( Goodell’s sign), the pregnant cervix feels like
lip of mouth, while in non-pregnant state like tip of nose.
 UTERIN
A) Size, shape and consistency :
E
 Uterus enlarged to: CHANG
• size of hen’s egg at 6th week.
•Size of cricket ball at 8th week.
ES
•Size of fetal head at 12th week.

 Pyriform shape of nonpregnant uterus becomes globular by 12th week. There may be
asymmetrical enlargement of uterus if there is lateral implantation.
( One half is more firm than other half. As pregnancy advances, symmetry is restored, uterus
feels soft and elastic)
 (CONT..
)
B) Hegar’s sign:

• It is present in two third of cases.

• It can be demonstrated between 6-10 weeks.
• It is softening and compressibility of the lower segment of the uterus felt on
bimanual examination ( Two fingers in anterior fornix and abdominal fingers behind
uterus).
C) Palmer’s sign:

Regular rhythmic uterine contraction on bimanual examination at 4-8

weeks .
 POSITIVE SIGNS COMMON TO
ALL
THREE TRIMESTER

IMMUNOLOGICAL
TEST ULTRASONOGRAPHY
 IMMUNOLOGICAL
TEST
URINE • Agglutination test
• Dip stick test
PREGNA • Enzyme linked monoclonal antibody tests.
NCY
TESTS:
• Fluoro-immunoassay (FIA)
• Radioimmunoassay (RIA)
SERUM • Immuno-radiometric assay (IRMA)
PREGNA • ELISA
NCY
TESTS
 SECOND
TRIMESTER
SUBJECTIVE SYMPTOMS
ENLARGEMENT DECREASE
AMENORRHOEA OF LOWER
ABDOMEN MORNING
SICKNESS

DECREASE
URINARY QUICKENING
SYMPTOM
S
 Second trimester
Objective symptoms

SKIN CHANGES VAGINAL ABDOMINAL

Cholasma CHANGES SIGNS
 ABDOMINAL
SIGNS

SKIN PALPATION AUSCULTATION

• LINEA NIGRA • FUNDAL HEIGHT • FETAL HEART SOUND:
• SHAPE & CONSISITENCY OF
• CHOLASMA UTERUS
GRAVIDARU • BRAXTON- HICKS • - UTERINE SOUFFLE
M CONTRACTION • -FETAL SOUFFLE
• PALPATION OF FETAL PARTS
• STRIAE
• ACTIVE FETAL
GRAVIDARUM MOVEMENTS
STRIAE
GRAVIDARUM
CHOLASMA
GRAVIDARUM
 FETAL HEART
FETAL HEART SOUND : SOUND
FHS is the most conclusive clinical sign of pregnancy.
It can be detected between 18-20 weeks by stethoscope.
The fetal heart rate varies from 110-160 beats/ min.
Two other sounds are confused with FHS. Those are:
UTERINE SOUFFLE:
It is soft blowing and systolic murmur heard low down
at the side of uterus, best on
left side.
This sound is synchronized with maternal pulse and is due to increase in blood flow
through dilated uterine vessels.
FETAL SOUFFLE or FUNIC :
It is due to rush of blood through umbilical artries. It is soft,
blowing murmur ,
synchronized with FHS.
 THIRD
TRIMESTER

SUBJECTIVE SYMPTOMS

OBJECTIVE SIGNS
 SUBJECTIVE
 Amenorrhoea.
SYMPTOMS
 Progressive enlargement of abdomen.
 Palpitation and dysponea following exertion due to enlarge abdomen.
 Lightening: At about 38 week, sense of relief of pressure symptoms obtained due to
engagement of presenting part.
 Frequency of micturition reappears.
 Fetal movements are more pronounced
 OBJECTIVE
SYMPTOMS
• Palpation of fetal parts.
• Palpation of fetal movements.
• Auscultation of fetal heart sound.
• Occasional auscultation of funic soufflé.
• Cutaneous changes are more prominent with increase
pigmentation and striae.
• Uterine shape is changed from cylindrical to spherical by
36th week.
• Fundal height: The distance between umbilicus and ensiform
cartilage is divided
into three equal parts
 FUNDAL
Pregnancy in weeks Fundal height
HEIGHT
At 32th week Junction of upper and middle third of ensiform cartilage
At 36th week Up to the level of ensiform cartilage.
At 40th week Down to the 32th week due to engagement of
presenting part.
THE POSTPARTAL FAMILY

Maybelle B.
 Postpartal
• Period
Puerperium- “puer”- child, “parere” brin
–to forth g

• 6-weeks period after childbirth

• Retrogressive- involution of the
uterus and vagina
• Progressive- production of milk for lactation,
restoration of the normal menstrual cycle, and
beginning of a parenting role
Psychological Changes of
the Postpartal Period
 PHASES OF
PUERPERIUM
Taking-In Phase
•2- to 3-day period, a woman is
largely passive
• woman usually wants to talk about
her pregnancy, especially about her
labor and birth
• ***Main nursing is to listen and help the mother interpret
events of the delivery to make them more meaningful
and clarify and misconceptions
 PHASES OF
PUERPERIUM
Taking-Hold Phase
– Occurs during day 1 - 3 following delivery.
– Marked by a period of being dependent and
passive behavior.
– Mother’s primary needsare her own -- food
and sleep
– Mother is talkative about her labor and
delivery experience

***It is the best time for teaching!

 PHASES OF
PUERPERIUM
Letting-Go Phase

• woman finally redefines her new role

• She gives up the fantasized image of
her child and accepts the real one; she
gives up her old role of being childless
or the mother of only one or two
Development of Parental Love
and Positive Family
1. En Relationship
Face position -- eye-to-eye
contact

2. Explore with finger-

tips

3. Hand and Palmar contact

4. Whole arms --enfolds whole

baby
close to body
 DPLPF
• R
Claiming or Bonding

The Claiming Process

Includes the
identification Of the
baby’s specific Features,
relating them To other
family members

“Those
long
 Rooming-
In
• Infant stays in the room rather than in
the nursery.

• She can become better acquainted with

her child and begin to feel more
confident in her ability to care
 Postpartal
• Bluesexperience some feeling
50% of women
of overwhelming sadness for which they
cannot account
• Hormonal changes- dec progesterone
and estrogen
• Response to dependence and low self
esteem caused by exhaustion, being
away from home, physical discomfort
and tension
 Postpartal
• Blues
Fearfulness, feeling of inadequacy,
mood lability, anorexia and sleep
disturbance

• Assurance and support

 Physiologic Changes of the Postpartal
Period
• Involution
– Reproductive organs
return to their normal
state
 Physiologic Changes of the Postpartal
Period
• Uterus
• 2 process
1. The area where the placenta is sealed off
– Accomplished by rapid contraction of the uterus after
the delivery of the placenta
– Muscle fibers become shorter controlling the bleeding
by compressing and sealing off blood vessels
2. The organ is reduced to its pregestational size
through
– Autolytic process
• Few cells of the uterine wall are broken down
into their protein component which is then
absorbed in the blood stream and excreted in
the urine.
– Contraction

- Immediately after birth – 1000g

- At the end of 1st wk- 500g
- 6wks – 50g
 Physiologic Changes of the Postpartal
Period
- After placental delivery
the uterus may be
palpated through the
abdominal wall halfway
bet the umbilicus and
the symphysis pubis
- 1hr after- level of
umbilicus
- Decrease 1 fingerbreath
per day
Assessment of the
Uterus
• Placement and Size
(location)

• Tone

• Lochia
 Nursing Care of Uterine
Changes
• Assessment of
the Uterus
– Placement and size --
should be level with the
umbilicus after delivery.
The uterus then should
decrease 1 FB / day.
Should also be midline and
the size of a grapefruit
 Nursing Care of Uterine
Changes
• Tone -- should be
firm. Assess by
supporting lower
portion with one
hand and palpate
fundus with other.
• If found boggy,
then massage.
Do not
overmassage.
 Lochi
TYPE a DURATION
COLOR COMPOSITI
ON
Lochia Rubra Red 1-3 days Blood,
fragments of
decidua,
mucus
Lochia Pink 3-10 days Blood,
mucus and
Serosa
leukocytes
Lochia Alba White 10-14 days Largely
mucus
 Characteristics of
• Lochia
Should not be excessive in amount
• Should not have an offensive odor
• Should not contain large pieces of
tissue or blood clots
• Should not be absent during the first
3 weeks
• Should proceed from rubra -- serosa
-- alba
 Physiologic Changes of
the Postpartal
• Cervix Period
– After birth- soft and
malleable, internal and
external os is open
– Pre-pregnant appearance
is a dimpled area in the
center -- post-
pregnancy appears as a
jagged slit.
 Physiologic Changes of
the Postpartal
Period
• Vagina

– May be edematous and bruised.

– Rugae begin to appear when ovarian
function returns.
– May teach the mom to do Kegels exercises
 Perineum
• May have tears, lacerations, or an episiotomy
• Assessment Procedure:
– Turn patient to side-lying / sims position
– Gently spread buttocks apart inspect
with penlight
Assessment:
– Episiotomy/lacerations/edema/hemorrho
ids
– Assess for complications/hematoma
Interventions:
– Hygiene/ Peri-bottle filled with
warm water
 Breast
• Teach to assesss
her own breasts --
similar to doing a self-breast exam
(SBE)
• Assessment:
– Breasts- nodules, lumps
– Nipples - assess for eversion, flat, inverted, cracking,
bleeding, pain, blisters

• Individualize teaching for breasts for

breastfeeding and non-
breastfeeding moms
 Process of Lactation

• Sucking of infant stimulates

the nerves beneath skin of
the areola to transmit
messages to the
hypothalamus

• Hypothalamus sends
messages to the pituitary
gland
 Process of Lactation
– Anterior pituitary -- stimulates
Prolactin to be released which is
the ultimate stimulation for milk
production
– Posterior pituitary --
stimulates the
releases Oxytocin which
contraction of the cells
the alveoli in thearound mammary
glands. This causes milk to be
propelled through the duct
system to the infant. This is the
“LET-DOWN” Felt as a
tingling sensation
reflex.
 Breastfeeding Care
• No soap on the nipples, wash in water wear
supportive bra
• Breastfeeding tips:
– Most important is the “latch-on” Teach measures to
assist with the infant getting the nipple and areola in
the mouth
– Teach different positions to hold the baby
– No timing
– Relax to allow for “let-down”
 Suppression of
Lactation
• Key: teach measures to
decrease stimulation of the
breasts
– Tight-fitting bra or binder
– Do not express milk from the
breasts
– Take showerwith back to the warm
water
– Ice packs
 Elimination Changes
Urinary System

• Assess and measure first two voidings post-

delivery.

• Important to attempt to void every 3 - 4 hours.

If unable to void– catheterize based on
assessment

• Diuresis is common -- loss of fluid of pregnancy

• Mild proteinuria is normal.

 Elimination Changes
Urinary System

• Patient Teaching:
– increase fluids, fiber, and activity
– stool softeners, anesthetic sprays, Tucks
– **Do NOT give an enema or suppository to
a person who has a 3rd or 4th degree
laceration.
 Regulatory
•
Changes
Most common problem is Sleep
deprivation -- the excitement and
exhilaration following the birth may
make it difficult to sleep.

• Exercise – Should be individualized

per patient. Use caution until
involution is complete.
 Postpartum Pain
– Perineal pain – result of trauma during delivery-
episiotomy/lacerations/hemorrhoids.
Interventions: Comfort measures: sitz, Tucks,
sprays / Foams, oral analgesics.

– Afterbirth pain -- more common in multigravidas

and breastfeeding moms. Interventions; Treat
with mild analgesics (NSAIDS, Acetomenophen)
heating pad, lie on abdomen, discontinue use
of oxytocins, Norco for severe pain
 Postpartum Pain

– Breast engorgement -- warm or cold packs, cabbage

leaves, increase feedings if breastfeeding, decrease
stimulation if not breastfeeding. Breast binder.

– Gas distention -- no ice chips or cold liquids, provide

warm / hot fluids, increase walking, rocking chair,
Simethicone.
 Integumentary
• Skin Changes
-- pigment changes will begin
to disappear; diaphoresis is normal

• Striae - May have stretch marks

over abdomen and legs

• diastasis recti- Can occur with

overdistention of the uterus, caution
with exercise
 Integumentary
Changes
• Episiotomy/lacerations – Important to
treat as any other incision and
maintain cleanliness

• C/S Incision – Maintain pressure dressing

for 24 hours and then open to air,
closure with staples/ steri
strips/dermabond. Document and assess
approximation, and signs of infection
 Oxygenation Alterations
Cardiovascular System
• Changes
Plasma volume – body rids itself of excess
by:
– Diuresis – urinary output of 3000 cc / day
is common
– Diaphoresis
• Blood Volume
– Increase for about 24-48 hours after
delivery
– Increase in blood flow back to the heart when
blood from the placenta unit returns to central
circulation
– Extravascular interstitial fluid is moved
 Oxygenatio
• Vital Signs n
– Temperature -- may see a SLIGHT ~100. rise in
temperature because of dehydration and exertion of labor
in first 24hrs

– Pulse -- Bradycardia is common for 6 - 8 days

postpartally. RT vagal response to increasedsympathetic
nervous system stimulation during labor and increase in
stroke volume.

– Respirations –begin to fall to normal pre-birth range.

– B/P -- should remain steady. Not elevated or

decreased
 Oxygenation – Lab Assessment
Pregnancy Post Partum

WBC – elevated slightly to about 12,000 WBC – leukocytosis is common with

values of 20,000 – 30,000 RT increassed
neutrophils

RBC – increase slightly to about 10 milion. RBC – return to normal

Hemoglobin – stays about normal at ~ 12 Hgb. – normal to see a drop of about 1

g. Below 10 g = anemia gram

Hemotocrit – lowers 33-39% RT Hct – normal to see a drop of about 4

hemodilution. If drops below 32- 35% = points and then a rise RT > loss of plasma
anemia than RBC death
• Assess for Thromboembolism

– During pregnancy, plasma fibrinogen

(coagulation) increases to prepare for
delivery and prevention of excess blood loss
– Plasminogen (lysis of clots) does not rise
– Hypercoagulable state and the woman is at
a greater risk for thrombus formation.
– Assess for homan’s sign?
– Assess for Hemorrhage -- related to
uterine atony
• Normal for loss of up to 500 cc during vaginal
delivery and 1000 cc in cesarean delivery.
• Assessment of lochia: should be scant to small with
no large clots.
• Assessment of fundus: tone, location
• If excess bleeding and decreased tone may
administer Methergine. Assess B/P prior to giving--
hold the dose if elevated >140 / 90. Other
drugs to contract uterus
 Nutritional
• Alterations
Most moms are hungry and eager to eat.
Progress slowly to avoid nausea and vomiting.

• Diet should include:

– High in Protein, vitamin C, and fiber
– Increase in fluids

• Lactating moms need about 500 extra calories

for milk production

• Prenatal vitamins and iron supplements are

often continued in the postpartum period.
“ Because the more a
mother is cared for,
the more easily she
can care for her
baby.”
- Shivam
Rachana
PHYSIOLOGY AND
MECHANISM OF LABOUR

Presented By
Ms.G.Thanga Anusha Bell,
M.Sc(N) II year
MMC, MADURAI
DEFINITION OF LABOUR
• Labour (parturition, childbirth, or birthing) is the
process by which the fetus and placenta are expelled
from the uterus and the vagina into the external
environment.
• Labour is the physiological process by which a viable
foetus and the products of conception i.e. at the end
of 28 weeks or more is expelled from the uterus.
TERMINOLOGIES
• Parturition is the birth process.
• A parturient is a woman in labour.
• Labour is a coordinated sequence of involuntary
uterine contractions that result in effacement and
dilatation of the cervix and voluntray bearing-down
efforts that result in delivery, the actual expulsion of
the products of conception, the fetus and placenta.
•
CONTD.,

• Dystocia is abnormal labour or difficult labour.

• Eutocia is normal labour;
• Delivery
It means actual birth of the foetus
Criteria for calling it Normal labour:
• Spontaneous expulsion, of a single and mature
foetus (37 completed weeks) .
• Presented by vertex and through the birth
canal.
• Presentation within a reasonable time (not less
than 3 hours or more than 18 hours).
• Without complications to the mother and or
the foetus.
ESSENTIAL FACTORS OF LABOUR

PASSENGER

PLACENTA PSYCOLOGI
CAL
5P’s RESPONSE

POWERS PASSAGE
 Essential Factors of labour

• THE PASSENGER-Fetal head size, Fetal lie,

presentation, attitude, position
• THE PASSAGE WAY
• THE POWERS
• THE PLACENTA
• PSYCHOLOGICAL RESPONSE
 The Passenger
• The passage of the fetus through the birth canal is influenced by the
size of the fetal head and shoulder,
the dimensions of the pelvic girdle,
 the fetal presentation and position.
The bones of the cranial vault are not firmly united, and
slight overlapping of the bones, or moulding of the shape of the head,
occurs during labour. This capacity of the bones to slide over one
another permits adaptation to the various diameters of the pelvis.
Moulding can be extensive, but with most neonates the head assumes
its normal shape within about 3 days after birth.
CONTD.,
The foetal head can move on the neck about 45 degrees
in flexion or extension and approximately 180 degrees
during rotation. This movement permits smaller diameters of
the foetal head to present during descent through the birth
canal.
Measurements of the foetal
skull 1)Anteroposterior
diameters
i) Occipitomental (OM): 13.5
ii) Occipitofrontal (OF): 11.5
iii) Suboccipitobregmatic (SOB):
9.5
2) Transverse diameters
i) Biparietal (Bip): 9.25
ii) Bitemporal (Bit): 8.0

Shoulders and Pelvic girdle

Because of their mobility, the position of the shoulder (the
shoulder girdle) can be altered during labour, so that one
shoulder may occupy a lower level than the other. This
permits a small shoulder diameter to negotiate the
passage. The circumference of the hips, or pelvic girdle, is
usually small enough not to create problems.
 Foetal lie
Lie is the relationship of the long axis
(spine) of the foetus to the long axis of
the mother.
There are two lie:
i)Longitudinal, in which the long axis of
the foetus is parallel with the long axis
of the mother, and
ii) Transverse, in which the long axis of
the foetus is at right
angles to that of the mother.
Presentation
Presentation refers to that portion of the fetus that enters the
pelvis first and covers the internal os of the cervix, such as
cephalic (vertex, head), breach or shoulder.

Attitude
Attitude is the relationship of the fetal body parts to each
other.
CONTD.,
1) The shape is roughly ovoid,
2)The back is markedly flexed,
3)The head is flexed on the chest,
4)The thighs are flexed on the
abdomen,
5)The knees are flexed at the
knee joints, and
6)The arches of the feet rest on the anterior surface of the legs; this is
the attitude of “general flexion”.
7)The arms are crossed over the thorax, and the umbilical cord lies
between them and the legs.
IN CEPHALIC
PRESENTATION
1. If the head is fully flexed on the chest, the occiput (vertex) presents first and the
posterior fontanel is palpable on vaginal examination; this is termed
an occipital, or vertex, presentation.
2.If the head is partially flexed or not flexed (moderate flexion), the anterior
fontanel presents and is palpable on vaginal examination; this is termed a sinciput
presentation or a military attitude.
3.If the head is markedly extended, the brow is the presenting part: this is
termed a brow presentation
4.If the head is hyper extended, the chin (mentum) is the presenting part; this is
termed a face or chin presentation
 Cause of Onset of Labour:
(1) Hormonal factors:
(i) Oestrogen theory
(ii) Progesterone withdrawal theory
(iii) Prostaglandins theory
(iv) Oxytocin theory
(v) Foetal cortisol theory
(2) Mechanical factors:
(i) Uterine distension theory:
(ii) Stretch of the lower uterine segment
 (1) Hormonal factors:
• (i) Oestrogen theory:
• During pregnancy, most of the oestrogens are present in
a binding form. During the last trimester, more free
oestrogen appears increasing the excitability of the
myometrium and prostaglandins synthesis.
• (ii) Progesterone withdrawal theory:
• Before labour, there is a drop in progesterone synthesis
leading to predominance of the excitatory action of
oestrogens.
(iii) Prostaglandins theory:
Postaglandins E2 and F2a are powerful stimulators of uterine
muscle activity
(iv) Oxytocin theory:
Although oxytocin is a powerful stimulator of uterine contraction ,
its natural role in onset of labour is doubtful. The secretion of
oxytocinase enzyme from the placenta is decreased near term due
to placental ischaemia leading to predominance of oxytocin’s
action.
(v) Foetal cortisol theory:
Increased cortisol production from the foetal adrenal gland before
labour may influence its onset by increasing oestrogen
production from the placenta
 (2) Mechanical factors:
(i) Uterine distension theory:
Like any hollow organ in the body, when the uterus in
distended to a certain limit, it starts to contract to
evacuate its contents. This explains the preterm labour in
case of multiple pregnancy and polyhydramnios.
(ii) Stretch of the lower uterine segment:
By the presenting part near term
 Clinical Picture of Labour

( A) Prodromal (pre - labour) stage:

(1) Shelfing, (2) Lightening, (3) Pelvic pressure symptoms,
(4) Increased vaginal discharge, (5) False labour pain.
(B) Onset of Labour:
(1)True labour pain, (2) The show, (3) Dilatation of the
cervix, (4) Formation of the bag of fore – water
 (A) Prodromal (pre - labour) stage:
• (1) Shelfing: It is falling forwards of the uterine fundus
making the upper abdomen looks like a shelf during
standing position.
• (2) Lightening:
• It is the relief of upper abdominal pressure symptoms as
dyspnoea, dyspepsia and palpitation due to :
• - Descent in the fundal level after engagement of the head
and
• - Shelfing of the uterus
(3) Pelvic pressure symptoms:
With engagement of the presenting part the following
symptoms may occur:
- Frequency of micturition.
- Rectal tenesmus.
- Difficulty in walking.

(4) Increased vaginal discharge.

(5) False labour pain:

 (B) Onset of Labour:

(1) True labour pain.

(2) The show:
(3)Dilatation of the cervix:
(4)Formation of the bag of fore – waters
PHYSIOLOGICAL EFFECTS OF LABOUR
(I) On the Mother:
(A) First stage-Minimal effects.
(B) Second stage:
-Temperature: slight rise to 37.5oC, - Pulse: increases up
to 100/min.
-Blood pressure: systolic blood pressure may rise slightly due to pain,
anxiety and stress.
- Oedema and congestion of the conjuctiva.
-Minor injuries: to the birth canal and perineum may occur
particularly in primigravidas
(C) Third stage:
Blood loss from the placental site is 100-200 ml and from
laceration or episiotomy is 100 ml so the total averageblood
loss in normal labour is 250 ml.
(II) On the Foetus:
(A) Moulding:
The physiological gradual overlapping of the vault bones as the
skull is compressed during its passage in the birth canal. One
parietal bone overlaps the other and both overlap the occipital
and frontal bones so fontanelles are no more detectable.
It is of a good value in reducing the skull diameters but;
severe and / or rapid moulding is dangerous as it may
cause intracranial haemorrhage.
 STAGES OF LABOUR
(I) First stage:
• It is the stage of cervical dilatation.
• Starts with the onset of true labour pain and ends with
full dilatation of the cervix i.e. 10 cm in diameter.
• It takes about 10-14 hours in primi gravida and about
6-8 hours in multi para.
First Stage: Phases of cervical dilatation:
(A) Latent phase:
This is the first 4 cm of cervical dilatation which is slow takes
about 8 hours in nullipara and 4 hours in multipara. The latent
phase begins with mild, irregular uterine contractions that soften
and shorten the cervix
(B) Active phase:
Begin after 4 cm of cervical dilatation. The normal rate of
cervical dilatation in active phase is 1.2 cm/ hour in primigravidae
and 1.5 cm/hour in multiparae. If the rate is < 1cm / hour it is
considered prolonged.
(C) Transitional phase

The transitional phase happens when the mother move from

the first stage of labour to the second, pushing stage. It
usually starts when her cervix is about 8cm (3.5in) dilated,
and end when her cervix is fully dilated, or when you get the
urge to push.
 (II) Second stage:
- It is the stage of expulsion of the foetus.
- Begins with full cervical dilatation and ends with the delivery of the
foetus.
- Its duration is about 1 hour in primigravida and ½ hour in
multipara.
-(ACOG) has suggested that a prolonged second stage of labor should
be considered when the second stage of labour exceeds 3 hours in
nulliparous and 2 hours in multiparous.
 (A) Delivery of the head:
(1) Descent:
It is continuous throughout labour particularly during the second stage
and caused by:
a. Uterine contractions and retractions.
b.The auxiliary forces brought by contraction of the diaphragm and
abdominal muscles.
c. The unfolding of the foetus
(2) Engagement:
The head normally engages in the oblique or transverse diameter of
the inlet.
(3) Increased flexion:
Increased flexion of the head occurs when it meets the pelvic floor
according to the lever theory.
Increased flexion results in :
a.The suboccipito - bregmatic diameter (9.5cm) passes through
the birth canal instead of the suboccipito- frontal diameter (10
cm).
b. The part of the foetal head applied to the maternal passages
is
like a ball. The circumference of this ball is 30 cm.
c.The occiput will meet the pelvic floor. Lever action producing
flexion of the head; conversion from occipitofrontal to
suboccipitobregmatic diameter typically reduces the
anteroposterior diameter from nearly 11.5- to 9.5 cm.
(4) Internal rotation:
The rule is that the part of foetus meets the pelvic floor
first will rotate anteriorly.
As the head descends, the presenting part, usually in
the
transverse position, is rotated about 45° to anteroposterior
(AP) position under the symphysis.

(5) Extension:
The suboccipital region lies under the symphysis then by
head extension the vertex, forehead and face come out
successively.
(6) Restitution:
After delivery, the head rotates 1/8 of a circle in the
opposite direction of internal rotation to undo the twist
produced by it.

(7) External rotation:

The shoulders enter the pelvis in the opposite oblique
diameter to that previously passed by the head. When the
anterior shoulder meets the pelvic floor it rotates
anteriorly 1/8 of a circle. This movement is transmitted to
the head so it rotates 1/8 of a circle in the same direction
of restitution
(B) Delivery of the shoulder and body:
The anterior shoulder hinges below the symphysis pubis and with
continuous descent the posterior shoulder is delivered first by
lateral flexion of the spines followed by anterior shoulder then
the body.
(III) Third stage:
- It is the stage of expulsion of the placenta and membranes.
- Begins after delivery of the fetus and ends with expulsion of the
placenta and membranes.
- Its duration is about 10-20 minutes in both primi and multipara.
 (IV) Fourth stage:
- It is the stage of early recovery.
- Begins immediately after expulsion of the placenta and
membranes and lasts for one hour.
- During which careful observation for the patient,
particularly for signs of postpartum haemorrhage is
essential. Routine uterine massage is usually done
every 15 minutes during this period.
 HYPEREMESIS
GRAVIDARUM
Mrs.Jagadeesw
ari.J
M.Sc Nursing
 INTRODUCTIO
HYPER : EXCESSIVE
NEMESIS : VOMIT
GRAVIDARUM : PREGNANCY

 Nausea/vomit of moderate intensity are

especially common until about 16
week.
 HCG occurs when vomiting becomes
intractable in early pregnancy & cause fluid &
electrolyte imbalances & nutritional deficiency.
 women usually needs to be hospitalized.
 DEFINITION
It is a severe type of
vomiting of pregnancy which
has got deleterious effect on
health of the patient and/or
incapacitates her day-to-day
activities
-D.C
.DUTTA
 ETIOLOG
Y
• Limited to 1st trimester
• More common in 1st pregnancy
• Tendency to recur again in subsequent
pregnancies
• Familial history: Mother and sisters also
suffer from the same manifestation
• More prevalent in hydratiform mole
and multiple pregnancy
• Common in unplanned pregnancies
 RISK
FACT
 Age below 17 ORSand over 35 years
years
 Primigravidae
 Multiple pregnancy
 Underweight and obesity
Psychological factors such as unwanted
Pregnancy ,marital problems
 H/O Hyper emesis Gravidarum
 Trophoplastic disease
 Theories behind Hyperemesis
Gravidarum
1.HORMONAL
• High Hcg-Hydratiform mole, multiple pregnancy
• High Estrogen
• High progesterone-relaxation of cardiac
sphincter
• Other hormones involved:
-Thyroxin
-Prolactin
-Leptin
-Adreno-cortisol hormones
 2.PSYCHOGENI
C
It probably aggravated
nausea once it begins
it trigger neurogenic
elements .
 3.DIETARY
DEFICIENCY
Probably due to low
carbohydrate reserve as it
happens after a night without
food. Deficiency of vitamin B1,B6
& protein may be the effect
rather than cause.
 Cont
…
4.Allergic or
immunological basis
5.Decrease gastric
motility is found to
cause nausea
 Clinical
Early: course
• Vomiting throughout day
• Normal day to day activities
are disturbed.
• No evidence of dehydration &
starvation
Late:
• Evidence of dehydration and
starvation
 Cont.
.
SYMPTOMS:
• Excess vomiting & retching day & night.
• Epigastric pain
• Constipation
• Ptyalism
• Spitting
• Fatigue
• Anorexia
• Complications will appear if not treated
 Cont.
Signs:
•
.
Signs of dehydration and
ketoacidosis
• Dry coated tongue
• Sunken eyes
• Acetone smell in breath
• Tachycardia
• Postural hypotension
• Raise in temperature
• Jaundice(later stage)
• Vaginal examination and
USG is done to confirm
pregnancy
 investigatio
1.Urinalysis n
• Quantity (too see for oliguria)
• Dark colour (due to concentration)
• High specific gravity with acid
reaction
• Presence of acetone, occasional
presence of protein and bile
pigments
• Diminished or even absence of
chloride
 Cont
…
2.Biochemical and circulatory
changes Serum
electrolytes
(Sodium,Pottasium and
Chloride) has to done
 Cont.
.
3.Opthalmoscopic
examination
Its is required if patients is seriously
ill. Retinal haemorrage and detachment
of the retina are the most unfavorable
signs
 Cont.
.
4.ECG
When there is abnormal
serum potassium level
 diagnosi
s
• Pregnancy is confirmed first
• Associated causes of vomiting are
excluded like Gynecological or
Medical or Surgical causes,
• USG –Pregnancy, Hydratiform
mole, Multiple pregnancy
 complication
sNEUROLOGICAL
1. Wernicke’s encephalopathy due to
thiamine deficiency
2.Pontine myelinolysis
3.Peripheral neuritis
4.Psychosis
5.Ophthalmic: Retinal haemorrhage
6.Convulsions
7.Coma
 Other
complications
• Stress ulcer in
the stomach
• Oesophageal
tears
• Jaundice due to
liver damage
 preventio
n
The only prevention is
to import effective
management to correct
simple vomiting of
pregnancy.
 managemen
t
Principles:
• To control vomiting.
• To correct fluid & electrolyte
imbalance.
• To correct metabolic
disturbance.
• To prevent serious complications of
severe vomiting.
 hospitalizatio
•
n
Admit the patient
• Open IV line and correct fluids
• Send for relevant investigations
• Maintain an intake-output chart
• Monitor urine output (catheterize the
patient)
• Monitor the vitals
• Test the urine periodically for ketone
bodies
 fluid
• Oral feeding is withheld for at least 24
s vomiting.
hours after the cessation of
• During this period, fluid given through IV drip
method.
• The amount of fluid to be infused in 24 hours is
calculated as: total amount of fluid approx.
3litres, of which half is 5% is dextrose and half is
Ringer’s solution.
• Extra amount of 5% dextrose equal to the
amount of vomitus and urine in 24 hours, is to
be added. These measures help to correct
dehydration, electrolyte imbalance and keto-
acidosis.
• Enternal nutrition through nasogastric tube
may
 drug
Antiemetic:-
s
• Promethazin -25mg IM BD
or TDS
• Trifluopromazine -10mg
IM
• Metachlopromide- 10mg
IM
• Hydrocortisone:- 100mg IV
in drip
• Prednisolone orally
• Nutritional support:-
 Nursing
• Sympathetic but firm care
handling of patient
• Daily monitoring of the patient
• Look for signs of improvement in the
patient: subsidence of vomiting, feeling
hungry, better look, disappearance of
acetone from breath and urine, normal
pulse and blood pressure, normal
urine output.
• Monitor lab results for dehydration
• Monitor FHR,Fetal activity and growth
• Encourage patient to sit in upright after
meal
• Encourage small & frequent meals.
• Liquids should be taken between meals
to avoid distending stomach and
triggering vomit
 Obstetric
care
• No therapeutic abortion
is indicated if patient
improve on therapy.
• Therapeutic abortion is
seldom indicated on
pregnancy associated
with renal or
neurological
complications.
 Dietary
•
management
Before IV fluids is given
oral Small and
frequent dry meals
without fat are given.
• First dry carbohydrates
like Biscuit, bread and
toast
• Ginger is helpful
• Gradually full diet is
restored